Loading...
HomeMy WebLinkAboutBLDG-19-002653 :-e-N.•. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -_fnr'J C€T( V14thi9 ,1' � /// ji� E �' 1/ /< 4C'J3 -36-6„ 1�4A DATE P._FtIJ�IT.� - � JOBSITE ADDRESS ?07l- iti-c_ Z? OWNER'S NAME CZ le-ti'eh_c � J OWNER ADDRESS TEL ` 44-3ll/FAX (v/ TYPE OROCCUPANCY TYPE COMMERCIAL[ 1.r EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[/4r APPLIANCES T FLOORS-4 BEIM 1 2 3 1 5 6 7 5 9 10 11 12 '13 14 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER —1 DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR. GRILLE I INFRARED HEATER i915 LABORATORY COCKS i MAKEUP AIR UNIT OVEN - _ i POOL HEATER ROOM!SPACE HEATER I ROOF TOP UNIT TEST UNIT HEATER UNVEINTED ROOM HEATER i WATER HEATER OTHER _ _ 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of 111IGL.Ch.'142 YES ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. i CHECK ONE ONLY: OWNER ❑ AGENT ❑ II SIGNATURE OF OWNER OR AGENT j : I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in compli e with all e 'nent provision of the - Massachusetts State Plumbing Code and Chapter'142 of the General Laws. / �1 l/ PLUMBER-GASFITTER NAMilee9A, t Pr D ITG (>'J 5,4„LICENSE#5' SIGNATURE MP 1 tvIGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑# LLC❑# COMPANY NAME ! G(t 4,0©,acii-li)-M- ADDRESS 2'5 60 .,4 #i CITY 40.-- -4&(c.A__ STATE A14 ZIP 0261 TEL ( 7�` U! �jL_D I 6 FAX CELL J��_� AIL `"�ILU�Ali/4-e� � ACAf1C ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTEt Yes N THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES